http://hhc.sagepub.com/ 

Home Health Care Management & Practice

http://hhc.sagepub.com/content/22/6/408The online version of this article can be found at:

 DOI: 10.1177/1084822309348896

2010 22: 408 originally published online 30 December 2009Home Health Care Management PracticeAnna C. Faul, Tara J. Schapmire, Joseph D'Ambrosio, Dennis Feaster, C. Shawn Oak and Amanda Farley

the Home Care WorkforcePromoting Sustainability in Frontline Home Care Aides: Understanding Factors Affecting Job Retention in

  

Published by:

http://www.sagepublications.com

can be found at:Home Health Care Management & PracticeAdditional services and information for     

http://hhc.sagepub.com/cgi/alertsEmail Alerts:  

http://hhc.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

http://hhc.sagepub.com/content/22/6/408.refs.htmlCitations:  

by tara schapmire on October 2, 2010hhc.sagepub.comDownloaded from

Home Health Care Management & Practice22(6) 408–416© 2010 SAGE PublicationsReprints and permission: sagepub.com/journalsPermissions.navDOI: 10.1177/1084822309348896http://hhcmp.sagepub.com

Promoting Sustainability in Frontline Home Care Aides: UnderstandingFactors Affecting Job Retention in the Home Care Workforce

Anna C. Faul, PhD,1 Tara J. Schapmire, MSSW,1 Joseph D’Ambrosio, JD, MSSW,1 Dennis Feaster, MSW,1 C. Shawn Oak, MSSW,1

and Amanda Farley, MSSW1

Abstract

With the growth of the older adult population increasing at an exponential rate, caring for this population has become increasingly difficult. As many choose to age in place (i.e., in the home environment), both the public and private sectors are being forced to respond. The emergence of home health care and the employment of home care aides is one of the ways that the industry has evolved to meet this crisis. However, retention of home care aides has proven problematic. This study explores factors affecting home care aide retention in agencies that employ home care aides. A sample of 116 home care aides employed by three agencies was surveyed to identify retention issues relative to the home care aide. A hypothetical model of home care aid job retention was tested with a hierarchical regression analysis, where 11 variables were entered in five steps, using a time-sequenced order. The results indicated that the hypothetical model was able to explain 41% of the variance in months employed as home care aides, with age, education, wages earned, and intrinsic satisfaction as the most significant contributors to the model. Being able to predict retention of home care aides allows employing agencies to realign themselves to retain workers and improve quality of care. However, it is important to realize that the same traits that predict retention among home care aides may also leave these workers vulnerable to exploitation.

Keywords

home care aides, job retention, turnover, older adults

Introduction

In recent years, the expanding population of those 65 and older in the United States has been a source of interest and concern. By 2008, the U.S. population of those 65 and older increased to 12.6% of the population (approximately 37.3 million people) and is expected to rise to 21% of the total population (or 86.6 million people) by 2050 (U.S. Census Bureau, 2009). This growth in the older adult population can be attributed to several factors, including the collective aging of the massive baby boomer generation and the prevalence of medical and pharmaceutical technologies that allow aging persons to live longer.

This aging population finds itself with numerous residen-tial options, although many prefer to remain at home in their older years (Hooyman & Kiyak, 2002). Baby boomers weaned on independence, thoughts of agelessness, and a desire to mai ntain their quality of life will continue to nurture the trend

to remain at home and avoid aging the way their parents aged (Boris & Klein, 2006; Novak, 2006). Economics also plays a big part in the decision to remain at home as the cost of alter-native living arrangements continues to increase and place burdens on personal finances. Also, the need for chronic home care increases as hospitals decrease the amount of time per-mitted during hospital stays (Kendra, 2002). Although older adults are healthy, remaining at home is not an issue, but once health-related illnesses occur, the choice to remain at home becomes difficult. Many studies conducted on aging populations have focused on the nature of the care that older persons receive, for instance, aging in place, as opposed to

1University of Louisville, Louisville, KY, USA

Corresponding Author:Anna C. Faul, Kent School of Social Work, University of Louisville, Louisville, KY 40292, USAEmail: anna.faul@louisville.edu

by tara schapmire on October 2, 2010hhc.sagepub.comDownloaded from

Faul et al. 409

leaving familiar environments and moving into some version of institutionalized care (e.g. assisted living, supported living, and long-term/intermediate care; Meagher, 2006; Montgomery, Holley, Deichert, & Kosloski, 2005; Osterhout & Zawadski, 2006). Because of the challenges that this presents to the tradi-tional health care system, this necessitated a number of changes to better meet the demands of consumers aging in place, one of the most significant of which is the rise of home health care services (Crown, 1994; Crown, Ahlburg, & MacAdam, 1995; Osterhout & Zawadski, 2006).

Home health care represents a large and growing industry and is funded through a variety of sources, one of the most important being Medicare. The 2000 U.S. Census revealed that the health care sector employed nearly 14 million people in a variety of positions, including home health professionals, such as nurses and allied health professions (physical thera-pists, occupational therapists, etc.), and nearly 800,000 of whom were home health and home care aides (Montgomery et al., 2005). The growing demand for these services has pla-ced a premium on the available supply (Crown et al., 1995). The increased demand for home health care is leading growth in the health care industry (Dansky & Brannon, 1996).

The position of the home care aide has received increas-ing scrutiny in recent years in the home health care industry. Home care aides represent a work force of approximately 767,000, with a projected growth to 1.2 million by 2016, which represents a 51% growth over 10 years (U.S. Bureau of Labor Statistics, 2008). The services that are provided by home care aides include “housekeeping, assistance with err-ands, accompanying individuals outside their homes, and assisting in . . . personal care” (Health Workforce Solutions, 2005). Without home care aides, the demand on families and informal caregivers to support older adults in their homes would be impossible in many cases (Boris & Klein, 2006).

The irony for those who work in these vital positions is that for all of the importance that society places on these services, the positions are considered to be low skilled and low status, and consequently, they receive low pay and work under a variety of difficult circumstances (Crown et al., 1995; Jacoby, 2006). Home care aide employment is characterized by low wages, minimal benefits, irregular hours of work, and unstable employment. Consequently, recruitment and reten-tion of this workforce is problematic (Feldman, 1993). Those who choose to enter this long-term care workforce are fre-quently marginalized populations themselves, mainly women who often come from disadvantaged economic and educa-tional backgrounds (Montgomery et al., 2005; Yamada, 2002). Given this set of factors, it is perhaps not surprising that the turnover among home care aides is significant, and retention of home care aides is proving difficult for the home care industry (Montgomery et al., 2005).

There have been several efforts in recent years to under-stand this institutionalized turnover. The cost of turnover in these positions to employers is significant in terms of training,

experience, and quality of care (Konrad, 2003). The cost to consumers is even higher, considering issues such as safety and the quality of the relationship with caregivers (Meagher, 2006). A number of studies have pointed out the part-time and temporary nature of the home care workforce, inferring that many home care workers also have other employment, perhaps for medical or other benefits (Crown et al., 1995; Yamada, 2002).

As a result of this increased investigation into this area, a number of tools have been developed to assist in identifying factors related to turnover in these key caregiving positions. Specifically, the U.S. Departments of Health and Human Services and Department of Labor collaborated in funding research that compiled a number of different tools to aid in assessing issues related to the experience of being a long-term care worker, including home care aides (Kiefer et al., 2005), some of which were used in this study.

Purpose of StudyThe purpose of the study was to understand the factors that affect job retention rates for home care aides. The hypotheti-cal model shown in Figure 1 drove this study. In the model, the different hypothesized explanatory factors affecting job retention that were investigated in this study are shown.

As can be seen from Figure 1, five blocks of variables were hypothesized as important predictors of job retention. These variables were selected after a literature review of possible factors influencing job retention of home care aides.

The first block in the hypothetical model is demograph-ics. With this block the model is trying to determine how much the individual characteristics of home care aides, namely, race, age, and education, affect job retention. With more than 88% of the workforce being women, it was not seen as important to investigate gender as part of this block (Montgomery et al., 2005). These characteristics are normally predisposing characteristics of people starting careers as home care aides.

Crown et al. (1995) and Yamada (2002) found that more than a third of home care aides (38%) never complete high school. Only 4% of home care aides have completed at least 4 years of college. The Defining the Frontline Workforce Study (Health Workforce Solutions, 2005) found that home care aides leave the profession because of many obstacles, of which few educational advancement opportunities are one. Given the fact that these frontline workers are normally from a low educational background, employed in a profession with very little opportunities for improvement of educational back-ground, educational level of the workers can be an important factor to consider in job retention. When workers realize that their profession is a dead end in terms of career prospects and better education, they may well decide to leave.

Crown et al. (1995) compared the demographics of home care aides, nursing home aides, and hospital aides. They found

by tara schapmire on October 2, 2010hhc.sagepub.comDownloaded from

410 Home Health Care Management & Practice 22(6)

that home care aides tend to be older than these other work-ers. It is possible that this age difference forms part of the problems associated with keeping home care aides in the profession. Because of low advancement opportunities, you nger workers tend to leave the profession seeking to find better opportunities elsewhere, whereas older workers tend to remain in their positions, perhaps because of their stage in life and the knowledge that the home care environment is less stressful then personal care delivery in other settings.

The home care profession tends to be characterized as a “minority” industry, meaning that the share of minority work-ers in this profession is substantially higher than that in the national workforce as a whole (Montgomery et al., 2005). For some reason this profession does not attract White work-ers, and therefore, race could be a predictor of retention.

The second block of variables in Figure 1 highlights salary (hourly wage) and benefits (health insurance) as hypothesized predictors of job retention. Montgomery et al. (2005), Yamada (2002), and Crown (1994) also discussed their findings with regard to the hourly wage paid to home care aides; all rep-orted home care aides as among the lowest paid workforce. Boris and Klein (2006) described the evolution of the direct care workforce in the United States and identified wages as being relevant to the retention of direct care workers (includ-ing home care aides), stating, “the labor remained so poorly

remunerated that most of those certified eventually left for restaurants, retail sales, and manufacturing” (p. 88). Presum-ably, if home care aides’ wages were competitive with these other industries, home care workers would not leave home care work because of wages alone.

The other variable in the second block in Figure 1 is that of benefits, which this study has limited to health insurance. Nearly half of the home care aides lack health insurance, according to a report by the Institute for Future of Aging Ser-vices (Lipson & Regan, 2004). Of those who are eligible for health insurance through their employer many find it cost pro-hibitive (Stowell-Ritter et al., 2003). Many are however not eligible because of their part-time status as home care aides (Crown, 1994). Osterhout and Zawadski (2006) addressed the benefit of health insurance as a potential predictor for home care aide retention. They reported that three annual studies of workers in Los Angeles County “show that homecare workers receiving medical benefits have a lower rate of turn-over and a higher rate of workforce stability” (p. 30).

Given the importance of job skills and the training that helps develop these skills, this study proposes quality of tra-ining (third block in Figure 1) as a potential predictive variable with regard to home care aide job retention. In a qualitative study of how home care aides assign meaning to their work, Stacey (2005) found a variety of motivations

Figure 1. Hypothetical model of job retention for home care aides

by tara schapmire on October 2, 2010hhc.sagepub.comDownloaded from

Faul et al. 411

among those employed as home care aides. Interestingly, she noted that although many in the health care industry and in the general population view home care work as being essentially a “dead-end job,” some home care aides themselves view their work as a means to receive the training that will enable them to either excel in their present positions or that would enable them to eventually move to a more desirable position. Regard-less, Stacey draws the important conclusion that,

irrespective of whether skills building provides home care aides with horizontal or vertical mobility within the job market, the perception of skill is central to the way that aides craft dignity on the job, countering mispercep-tions that caregiving is work “anyone can do.” (p. 847)

Despite the importance of training, not many resources are put into training entry-level workers, because of high initial turnover (Health Workforce Solutions, 2005).

The fourth block in Figure 1 hypothesizes work condi-tions as additional predictors of job retention. Stacey (2005) writes at length about the unique employer/employee rela-tionship that occurs in the home care context:

Home care workers interviewed describe a sense of practical autonomy that comes from having the freedom to informally negotiate certain terms of employment with clients, depending on client needs and level of functioning (i.e. what time to arrive and depart; when to perform certain caregiving tasks). In both the context of CHS and for-profit home care, all aides—in some way or another—seek out and hold on to jobs where they have some flexibility to determine hours worked and control over care. Some workers describe this as a sense of “being your own boss,” while others simply like the fact that they can work with the client to determine when and how to provide care. (pp. 845-846)

Given that Stacey (2005) identified areas that promote home care workers to seek out jobs that offer them a working envi-ronment that provides them with some level of autonomy and independent decision making, this study uses the relationship with the employer, employer encouragement, and problems with supervisor as being potential predictors with regard to home care aide retention.

The category of “other problems” in the work conditions block (Figure 1) relates to many of the stresses and strains that home care aides may experience in the course of their daily work activities, especially in the course of direct client care. Dale, Brown, Phillips, and Carlson (2005) and Muntaner et al. (2006) identified and addressed both emotional and physical demands related to direct care worker well-being. Consequently, the present study hypothesizes potential pre-dictive value in terms of home care aide retention with regard to additional perceived problems related to emotional and

physical demands, for example, physical strains (catching an illness or getting hurt) and emotional strains (facing difficul-ties because of race or gender issues).

Workers’ experience of respect by their client systems is another important variable that forms part of work conditions. According to Dale et al. (2005), 12.4% of workers employed by agencies desire more respect from their clients, and 22.4% desire more respect from the families and friends of their cli-ents. Not having respect from the people you work with closely can result in additional emotional strains; therefore, client sys-tem respect was included in the predictive model.

Intrinsic rewards are the last hypothesized predictor of job retention in the model for this study (Figure 1, fifth block). Given that home care aides receive relatively low wages for doing work that many others may well find distasteful (per-sonal care, toileting, and hygiene assistance, for example), the researchers wrestled with the question of why people chose to work as a home care aides when they could get a job with an organization that paid more, offered more and better fringe benefits, and did not require the aforemen-tioned “dirty work” for entry-level workers. Stacey (2005) addresses this, writing:

For home care aides, however, there is also a third reward—doing dirty work—that is unique to the car-egiving relationship, and is relational (rather than individual) in nature. Workers draw meaning from their willingness and ability to perform dirty and mundane tasks that others avoid, knowing that their efforts improve the lives of clients. Taking on dirty work, therefore, is an important source of dignity for workers whose labour is invisible and undervalued by the general public. (p. 845)

This, combined with the intrinsic satisfaction many derive from helping others, may well account for the decision to become and remain a home care aide and therefore was included in the model.

The research questions driving the study were the following:

Research Question 1: What factors (demographics, sal-ary and benefits, training effectiveness, work condi-tions, and intrinsic rewards) predict length of time working as a home care aid?

Research Question 2: Are there any factors that do not contribute significantly to the prediction model?

MethodsDesign

A quantitative, nonexperimental, contextual cross-sectional survey design was used to answer the research questions. The institutional review board of the University of Louisville

by tara schapmire on October 2, 2010hhc.sagepub.comDownloaded from

412 Home Health Care Management & Practice 22(6)

approved this study. In an effort to isolate the identified pre-dictors of job retention, data were gathered—at essentially one point in time—from three Area Agencies on Aging (AAAs) who contracted home care service providers.

ParticipantsA convenience sampling method was used to include as many home care aides as possible in the study. The sample con-sisted of 116 home care aides employed by home care service providers contracted by the following AAAs within the Ken-tucky Office of Aging Services representing five regions in Kentucky: KIPDA (N = 90), Lincoln Trail AAA (N = 19), and Northern Kentucky AAA (N = 7).

Data CollectionData were collected using two different methods. In the KIPDA and Lincoln Trail regions, data were collected at the mandatory annual trainings completed by home care aides. The study was advertised at the offices of the different home care aide service providers. During the training sessions, the research team administered the survey to the participating home care aides, after informed consent was obtained. In the Northern Kentucky region, the surveys were delivered to the offices of two of the contracted home care aide service pro-viders. The surveys were given to the home care aides and returned in sealed envelopes by the employees who chose to participate. Data was collected over a time period of 6 months.

MeasuresThe survey consisted of 25 items and was modeled after the Better Jobs Better Care Survey of Direct Care Workers (BJBC). The BJBC Survey was developed as part of a 4-year, $15.5 million program funded by The Robert Wood Johnson Foundation and The Atlantic Philanthropies (Kiefer et al., 2005). The different parts of the conceptual model (Figure 1) were measured as follows.

Demographics. Age and education were measured in years. Ethnicity was recorded as either White or Other Race. Gender was not included in the analysis, because of the homogeneity of the sample (97% female).

Salary and benefits. Salary was measured in hourly wages. Health insurance was measured by asking if it was offered or not offered by the agency.

Training effectiveness. Training effectiveness was mea-sured by listing 12 specific training topics relevant to the job performed by home care aides. Aides had to rate the useful-ness of the training on each of the topics with scores that could range between 1 = not at all useful and 4 = extremely useful.

Work conditions. The relationship with their employers was measured by asking them if they would recommend the

services provided by the employers to friends or family members. They were also asked if they would recommend their employers as a place to work. These two items were measured on a scale that ranged from 1 = definitely recom-mend it to 4 = definitely not recommend it. Employer encouragement was measured with one item, asking the employee if his/her employer is doing anything out of the ordinary to improve their job or to encourage them to keep working there. The item was measured on a scale that ranged from 1 = never to 4 = all the time. Five items were used to measure problems with supervisor, namely, not having sup-port from supervisor, unrealistic expectations from supervisor, not using skills, not being valued by supervisor, and supervi-sor not being good at the job. These items were measured on a scale that ranged from 1 = not at all a problem to 4 = an extremely big problem. These five items had an internal con-sistency coefficient of .87. Four items were used to measure other potential work problems, namely, catching an illness, getting hurt, facing difficulties because of race or ethnicity, and facing difficulty because of gender issues. These items were measured on the same scale as indicated above. These four items had an internal consistency coefficient of .79. Client system respect was measured with two items, namely, if their clients and their families respect them as part of the health care team. These items were measured on a scale that ranged from 1 = strongly disagree to 4 = strongly agree.

Intrinsic satisfaction. Intrinsic satisfaction was measured with a 19-item scale asking questions about the rewarding part of their job, for example, helping others, feeling a sense of accomplishment, feeling needed by others, being valued, and having a job that fit interests. The items were measured on a scale that ranged from 1 = not at all rewarding to 4 = extremely rewarding. The scale had an internal consistency coefficient of .86.

Time worked as home care aide. This item was measured in months and asked the respondents how long they have been employed as home care aides.

AnalysisA hierarchical regression analysis was done to test the hypo-thetical model. The predictor variables were entered in five blocks, using a time-sequenced order. All the tests used in the analysis are based on the assumption of normality. To ensure that this assumption was not violated, a total of five variables had to be transformed. Client respect was negatively skewed and transformed with a reflected log transformation. Relationship with employer, other problems, and problems with supervisor were all positively skewed and transformed with a log transformation. Time worked as a home care aide was positively skewed and transformed with a square root transformation. Three percent of the values on different items related to the predictor variables were randomly missing and replaced with the agency mean for that variable. A total of

by tara schapmire on October 2, 2010hhc.sagepub.comDownloaded from

Faul et al. 413

101 cases were included in the final analysis; 13 were rem-oved because of missingness on the dependent variable, and two multivariate outliers were removed from the analysis. Because of the use of 11 variables in the analysis, and the relatively small sample size, a priori power analysis sug-gested that the detection of only a large effect size would be possible for the ideal power of .80. To adjust for this prob-lem, the alpha level was set at .10 to enable at least a power of .80 for a medium effect size.

ResultsIn this section, the participants are first described in terms of the predictor and criterion variables, after which the results of the model testing are shown.

Description of Participants: Predictor VariablesDemographics. Participants were predominantly Cauca-

sian (N = 70; 61%), female (N = 111; 97%), ranging in age from 20 to 80 years (M = 50; SD = 14.4). Participants’ years of formal education (starting at first grade) ranged from 1 to 18 (M = 12; SD = 2.1). Twenty percent did not complete high school, nearly half (47%) completed high school, 14% com-pleted an associate degree, and 19% had education higher than an associate degree.

Wages and benefits. Hourly wages ranged from $6.75 to $11.75 (M = 8.74; SD = 1.02). Close to two thirds of the sample (N = 66; 61%) were not offered health insurance by their agency.

Training effectiveness. Mean scores for all the topics cov-ered ranged between 1.6 and 4, with a mean of 3.13 (SD = 0.61), a median of 3.17, and a mode of 3.0 indicating train-ings offered were considered very useful.

Work conditions. The sample rated their work conditi ons as satisfactory. Specifically, the scores on the relationship with employer variable for the two items ranged from 2 to 8, with a mean of 3.13 (SD = 1.39) and a median of 3, indi-cating they would recommend their agencies for care and employment. Employer encouragement scores ranged from 1 to 4, with a mean of 2.77 (SD = 1.01), a median of 3, and a mode of 3, indicating that participants felt employ-ers did things to improve their job or encourage retention at least some of the time. Problems with supervisor scores for the five items ranged from 5 to 20, with a mean of 8.41 (SD = 4.07), indicating minimal problems. Other potential work problems scores ranged from 4 to 16, with a mean of 6.12 (SD = 2.70), indicating minimal problems. Client system respect scores ranged from 2 to 8, with a mean of 7.22 (SD = 1.41). Participants felt respected by clients and families.

Intrinsic satisfaction. The last predictor variable, intrinsic satisfaction, had scores ranging from 38 to 75, with a mean of 62.64 (SD = 8.34), indicating that participants rated their work to be very rewarding.

Description of Participants: Criterion Variable

Time worked as a home care aide ranged from 1 month to 480 months (40 years), with a mean of 102.27 months (8.5 years; SD = 99.76 months); median months worked was 60 (5 years), and mode was 12 months.

Model TestingThe results of the model testing are provided in Table 1.

Hierarchical regression analysis was used to explore which of the 11 predictor variables were the best predictors of job retention. Predictor variables were entered in five blocks. In the first step, only demographic variables (age, ethnicity, and education) were entered as predictors. As can be seen in Table 1, all three variables showed strong predictive ability, with the overall model predicting 15% of the variance in months employed as a home care aides (R2 = .15; F(3, 97) = 5.87; p = .001). Adding the salary and benefits variables in the second step improved the model significantly, with the overall model predicting 32% of the variance in months employed as a home care aides (R2 = .32; F(5, 95) = 9.09;p = .001). After training effectiveness was added in the third step, the model improved significantly, with the overall model predicting 34% of the variance in months employed as a home care worker (R2 = .34; F(6, 94) = 8.17; p = .001). The addi-tion of the five work condition variables in the forth step did not significantly improve the model. The overall model pre-dicted 39% of the variance in months employed as home care aides (R2 = .39; F(11, 89) = 5.13; p = .001). The addition of the fifth and final step—intrinsic satisfaction—signifi-cantly improved the model, with the overall model predicting 41% of the variance in months employed as a home care worker (R2 = .41; F(12, 88) = 5.07; p = .001). In this final model, the significant predictors from block one were age (b = .19; p = .03) and education (b = .20; p = .02), from block two wages (b = .38; p = .001) and from block five intrinsic satisfaction (b = .17; p = .08). No variables from the training effectiveness block or the work conditions block contributed to the model.

DiscussionRetaining workers in a low-pay, limited benefits, physically challenging job is difficult in any industry and home care aides are no exception. Given the dramatic increase of elders that has been predicted in the population over the coming decades, the importance of a stable home care workforce in providing services to this population is of vital importance. Being able to isolate the variables that predict retention among this work-force will allow employing agencies to adjust to the needs of these workers, thereby promoting fair work practices and, indirectly, better care for the client population.

The results of this quantitative study support prior findings and assertions and suggest that home care aides could remain

by tara schapmire on October 2, 2010hhc.sagepub.comDownloaded from

414 Home Health Care Management & Practice 22(6)

Table 1. Hierarchical Regression Analysis (N = 101)

Variables B SE B b

Step 1 Demographic variables

Age 0.09 0.03 0.26**White ethnicity -1.76 0.90 -0.18*Education 0.45 0.21 0.20**

Step 2 Demographic variables

Age 0.07 0.03 0.21**White ethnicity -1.02 0.84 -0.11Education 0.41 0.19 0.18**

Salary and benefits Wages 1.57 0.42 0.34***Health insurance -1.79 0.85 -0.19**

Step 3 Demographic variables

Age 0.06 0.03 0.19**White ethnicity -1.03 0.83 -0.11Education 0.43 0.19 0.19**

Salary and benefits Wages 1.61 0.42 0.35***Health insurance -1.76 0.85 -0.18**

Training Training effectiveness 1.07 0.64 0.14*

Step 4 Demographic variables

Age 0.06 0.03 0.18**White ethnicity -1.52 0.88 -0.16*Education 0.41 0.19 0.19**

Salary and benefits Wages 1.73 0.43 0.38***Health insurance -1.40 0.87 -0.15

Training Training effectiveness 1.10 0.67 0.15

Work conditions Relationship with employer 2.93 2.68 0.11Employer encouragement -0.36 0.47 -0.08Problems with supervisor -1.13 0.81 -0.16Other problems -0.80 3.47 -0.03Client respect -2.07 1.72 -0.11

Step 5 Demographic variables

Age 0.06 0.03 0.19**White ethnicity -1.28 0.88 -0.13Education 0.45 0.19 0.20**

Salary and benefits Wages 1.76 0.43 0.38***Health insurance -1.16 0.87 -0.12

Training Training effectiveness 0.69 0.70 0.09

Work conditions Relationship with employer 4.22 2.74 0.16Employer encouragement -0.33 0.46 -0.07Problems with supervisor -1.25 0.81 -0.18Other problems 1.36 3.44 -0.05Client respect -2.01 1.70 -0.11

Intrinsic satisfaction Intrinsic satisfaction 0.10 0.06 0.17*

Note: R2 = .15 for Step 1; DR2 = .17 for Step 2 (p = .001); DR2 = .02 for Step 3 (p = .10); DR2 = .05 for Step 4 (p = .27); DR2 = .02 for Step 5 (p = .08).*p < .10. **p < .05. ***p < .01.

by tara schapmire on October 2, 2010hhc.sagepub.comDownloaded from

Faul et al. 415

on the job longer when certain variables are taken into consid-eration, namely, age, education, salary, and intrinsic satisfaction. The literature confirms that younger workers are more likely to leave a low paying profession with fewer prospects for advancement. Older workers, however, appear to be less likely to leave because of their stage of life (Crown et al., 1995). Also, older workers potentially may prefer to work in an environ-ment where they enjoy autonomy and without the constraints of a direct supervisor. Home care aides mostly work inde-pendently, therefore the environment fits within the life stage of older workers.

The study indicates that more years of education will result in higher retention. The less educated workers seek profes-sions where there are opportunities for advancement. Without this opportunity they are sometimes forced to leave the pro-fession to find a career where they can improve their educational levels (Health Workforce Solutions, 2005).

The study confirms that if home care aides’ wages were competitive with other industries, home care workers would not leave home care work because of wages alone. Wages was one of the strongest predictors in the model, indicating that it is important to pay attention to the low wages received by home care aides. Health Workforce Solutions (2005) clearly indicates the problems associated with low wages and advo-cate for policies to remedy the situation.

In the analysis of this helping profession, it was no sur-prise that intrinsic satisfaction was a significant predictor in this model. These workers gain significant rewards from providing care, and sometimes these rewards may over-shadow the problems associated with low wages, lack of advancement opportunities, and difficult working conditi-ons. However, the interplay between the importance of intrinsic rewards and low wages discussed previously leave these workers vulnerable to exploitation. Care should be taken by employing agencies to ensure appropriate remu-neration for these vital frontline workers.

Although the training effectiveness and the work condi-tions blocks in the hypothetical model did not show any significant predictors in the final model, it is important to realize that the sample for this study had unique circum-stances that may have prevented these variables from being significant. A large portion of the sample worked in a region that recently instituted mandatory training for all home care workers. This training has been seen as effective in dealing with the training needs of the workers, with almost all par-ticipants feeling very satisfied with the training. Therefore, there was not enough variance in the training effectiveness variables to make this a significant predictor for this sample. Furthermore, the employers of the home care aides all indi-cated relatively good relationships with their workers, resulting in the variables related to the work conditions not showing any predictive power that could explain the differ-ence between respondents with varying times employed as home care aides.

As the demand for these workers increases, so will the col-lective power of this workforce. Being able to identify ways to align with their needs and interest now will allow for a smooth transition to the changing needs of the overall population.

LimitationsThe study has a few specific limitations, of which sample size, generalizability of results, and socially desirable responses are the most important. Because a convenience sample was used, results from this study cannot be generalized to a target popu-lation and should be interpreted with caution, although they do indicate a need for increased research in this area beyond the home care aides surveyed. The sample size is relatively small, but the decentralized nature of home care work and the diffi-culty in getting large numbers of study participants together at the same time proved to be problematic. Although participants were assured that individual survey results would not be rep-orted, some expressed concern that their participation would negatively affect their job status or their relationships with their employers. This fear may have affected their responses, specifi-cally in relation to the work conditions block in the hypothetical model.

ConclusionAlthough salary and benefits appear to be the solution that employers think about to increase job retention in our declin-ing economy, alternative factors need to be considered. This study, although showing that age, education, and salary sig-nificantly influence job retention, indicates intrinsic satisfaction must also be taken into account when trying to improve job retention of home care aides. Home care aides, like many in the “helping professions,” do what they do because they get intrinsic satisfaction, and this appears to override the effects of low pay. Ethically, employers should also be aware of the importance placed on intrinsic satisfaction by home care aides and the possibility of taking advantage of employees who do a job because it makes them feel good. The danger of this is that it could lead to the oppression and abuse of this vital seg-ment of the workforce that provides a significant addition to the health care industry.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The authors received no financial support for the research and/or authorship of this article.

References

Boris, E., & Klein, J. (2006). Organizing home care: Low-waged workers in the welfare state. Politics & Society, 34(1), 81-108.

by tara schapmire on October 2, 2010hhc.sagepub.comDownloaded from

416 Home Health Care Management & Practice 22(6)

Crown, W. H. (1994). A national profile of homecare, nursing home, and hospital aides. Generations, 18(3), 29-33.

Crown, W. H., Ahlburg, D. A., & MacAdam, M. (1995). The demo-graphic and employment characteristics of home care aides: A comparison with nursing home aides, hospital aides, and other workers. The Gerontologist, 35(2), 162-170.

Dale, S., Brown, R., Phillips, B., & Carlson, B. L. (2005). How do hired workers fare under consumer-directed personal care? The Gerontologist, 45(5), 583-592.

Dansky, K. H., & Brannon, D. (1996). Using TQM to improve man-agement of home health aides. Journal of Nursing Administra-tion, 26(12), 43-49.

Feldman, P. H. (1993). Work life improvements for home care work-ers: Impact and feasibility. The Gerontologist, 33(1), 47.

Health Workforce Solutions. (2005). Defining the frontline work-force. Princeton, NJ: Robert Wood Johnson Foundation.

Hooyman, N. R., & Kiyak, H. A. (2002). Social gerontology: A multidisciplinary perspective (6th ed.). Needham Heights, MA: Allyn & Bacon.

Jacoby, D. (2006). Caring about caring labor: An introduction. Poli-tics & Society, 34(1), 5-9.

Kendra, M. A. (2002). Perception of risk by administrators and home health aides. Public Health Nursing, 19(2), 86-93.

Kiefer, K. M., Harris-Kojetin, L., Brannon, D., Barry, T., Vasey, J., & Lepore, M. (2005). Measuring long-term care work: A guide to selected instruments to examine direct care worker experi-ences and outcomes. Washington, DC: U.S. Department of Health and Human Services and Department of Labor.

Konrad, T. R. (2003). Descriptive results from the annual short turnover surveys conducted for the office of long-term care of the NC Department of Health and Human Services. Chapel Hill: North Carolina Institute on Aging.

Lipson, D. & Regan, C. (2004). Health insurance coverage for direct care workers: Riding out the storm Better Jobs Better Care (Vol. 3). Washington DC: Institute for the Future of Aging Services.

Meagher, G. (2006). What can we expect from paid carers? Politics & Society, 34(1), 33-53.

Montgomery, R. J. V., Holley, L., Deichert, J., & Kosloski, K. (2005). A profile of home care workers from the 2000 Census: How it changes what we know. The Gerontologist, 45(5), 593-600.

Muntaner, C., Li, Y., Xue, X. N., Thompson, T., Chung, H. J., & O’Campo, P. (2006). County and organizational predictors of depression symptoms among low-income nursing assistants in the USA. Social Science & Medicine, 63(6), 1454-1465.

Novak, M. (2006). Issues in aging (2nd ed.). Boston: Allyn & Bacon.Osterhout, R., & Zawadski, R. (2006). On homecare workforce. Pol-

icy & Practice of Public Human Services, 64(1), 30.Stacey, C. L. (2005). Finding dignity in dirty work: The constraints

and rewards of low-wage home care labour. Sociology of Health & Illness, 27(6), 831-854.

Stowell-Ritter, A (2003). Iowa long-term care: A synthesis of con-sumer and provider research. Des Moines, IA: Iowa Department of Elder Affairs. AARP.

U.S. Bureau of Labor Statistics. (2008). Occupational outlook hand-book. Retrieved February 4, 2009, from http://www.bls.gov/oco/

U.S. Census Bureau. (2009). American Community Survey. Retrieved February 2, 2009, from http://factfinder.census.gov

Yamada, Y. (2002). Profile of home care aides, nursing home aides, and hospital aides: Historical changes and data recommenda-tions. The Gerontologist, 42(2), 199-206.

Bios

Anna C. Faul, PhD, is a Hartford Faculty Scholar and Associate Dean of Academic Affairs at the Kent School of Social Work. She teaches advanced research and statistics in the PhD program at Kent School.

Tara J. Schapmire is a PhD student in social work at the Kent School of Social Work.

Joseph D’Ambrosio is a PhD student in social work at the Kent School of Social Work.

Dennis Feaster is a PhD student in social work at the Kent School of Social Work.

C. Shawn Oak is a PhD student in social work at the Kent School of Social Work.

Amanda Farley is a PhD student in social work at the Kent School of Social Work.

by tara schapmire on October 2, 2010hhc.sagepub.comDownloaded from